Experience with 969 Minimal Access Colectomies: The Role of Hand-Assisted Laparoscopy in Expanding Minimally Invasive Surgery for Complex Colectomies

Abstract

Laparoscopic-assisted colectomy (LAC) is not performed widely despite numerous patient benefits. LAC is difficult to perform and the learning curve is steep. Hand-assisted laparoscopy (HALS) permits placement of a hand into the abdomen to assist the dissection. Our aim was to analyze the impact of HALS on a minimal access colectomy (MAC) practice. A prospectively maintained database was retrospectively reviewed for all LAC and HALS colectomies. HALS was introduced in November 2003, and analysis was performed for the ensuing 3-year period. Procedure types, conversion rates, operation duration, complications, and length of stay were determined. During the study period, 969 MACs were performed (373 HALS, 596 LAC). Although HALS was used for all types of colorectal resection, it was most commonly used for complex colectomies (left-sided and total colectomies). HALS complex colectomies increased 44% from 2004 to 2005, and 24% from 2005 to 2006. Conversely, LAC complex colectomies decreased 29% (2004 to 2005) and then increased 27% (2005 to 2006). There were no demographic differences between patient groups. For complex colectomies, HALS substantially reduced operative time (mean ± SD; LAC, 258 ± 90 minutes; HALS, 242 ± 89 minutes; p = 0.037) and conversion rate (LAC, 15.3% versus HALS, 3.4%, p < 0.001), with the same complication rate (LAC, 13.6%; HALS, 15.4%; p = 0.629). The average length of stay (mean ± SD) was increased 1 day in the HALS group (LAC, 5.0 ± 3.0 days; HALS, 6.0 ± 3.4 days; p < 0.001), likely because of the higher proportion of total colectomies. HALS increased the number of MACs performed. More notably, HALS was used preferentially for complex colectomies. HALS effectively bridges the complexity divide between minimal access and open procedures. HALS may serve as a technology to expand MAC.